MJCC Rental Participation Waiver
Please complete a separate waiver form for each participant. At the end of the form, there is an option to submit a new response.
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Participant Information
Participant's Full Legal Name: *
Date of Birth: *
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Address: *
City: *
State: *
Zip Code: *
Phone #: *
Email address: *
If completing for a minor, please provide parent/guardian's email address.
MJCC Facility Use *
Use of any recreation facility and participation in any activity involves risk and accidental injury despite all safety precautions. Having been informed of the activities to be conducted at the Mittleman Jewish Community Center (MJCC) and/or Portland Jewish Academy (PJA) I/we, as an individual or parent/guardian of the participants named herein, assume all risks and hazards incidental to the activities, and release from responsibility all liability, claims, costs, and damages including attorney fees and costs. I also agree to indemnify and hold harmless MJCC and/or PJA, their officers, directors, independent contractors, volunteers, and all employees for any illness, injury or damage to me, or my children, or other family members occurring during the use of any recreational facility or the participation in any activities conducted by the MJCC and/or PJA. I understand that if I am presently under a doctor’s care that I have received his/her permission to exercise or participate in a workout program at the MJCC and/or PJA.
COVID-19 Consent Acknowledgement of Risk + Release
The Mittleman Jewish Community Center (MJCC) requests all members and guests who use or visit the
MJCC’s facilities to follow the most current guidelines issued by the Centers for Disease Control and
Prevention (CDC) for best practices to avoid influenza and respiratory illnesses such as COVID-19. The CDC’s recommendations include proper hygiene techniques, proper sanitation of equipment before and after use, physical distancing, and submitting to temperature checks and screenings prior to MJCC access. The CDC’s COVID-19 homepage, with links to guidelines, can be found here: www.cdc.gov/coronavirus/2019-nCoV/index.html
I have not experienced one or more symptoms associated with COVID-19 or any communicable disease within the last 14 days (including fever; cough; shortness of breath or difficulty breathing; chills or repeated shaking; runny nose; fatigue; sore throat; muscle pain; headache; loss of taste or smell; fatigue), and am not within a quarantine period as recommended by a healthcare provider. Any individual who experiences these symptoms while on the MJCC premises must leave immediately. *
I am electing to enter the MJCC and participate in rental activities at my own risk. I hereby acknowledge and assume the risk of becoming infected by COVID-19 by being at the MJCC and assume all economic risks resulting from such infection. I further acknowledge and agree that I expressly assume any risks associated with accessing or using the MJCC facilities, including exposure to third parties and any illnesses or communicable diseases they may be carrying. *
I agree that I may be subject to a temperature check and screening each time I visit or enter the MJCC’s facilities. I understand that the screening is not diagnostic, and it only seeks to determine whether I have symptoms currently associated with COVID-19. I authorize the MJCC or its designee to take my temperature and ask questions about my potential exposure to and symptoms associated with COVID-19.
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Signature: *
Must be 18 years and older. If participant is younger, parent/legal guardian should sign.
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